OCT 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 76 of 168

74 To continued from page 73 those manufactured by MicroSurgi- cal Technology, Redmond, Wash.) may be useful with less risk of capsu- lar damage. He uses an intraocular endo- scope (endocyclophotocoagulation unit, Endo Optiks, Little Silver, N.J.) while suturing to the ciliary sulcus or iris root. The unit allows him to see exactly where the sutures should be placed and place them there without damaging the ciliary body. "I use a combination of direct visualization of the placement of the suture needle, coupled with transil- lumination of the sclera ab interno from the coaxial illumination of the probe, to assess the scleral wall position of the ab externo suture," Dr. Rosenthal said. The importance of instrumentation The use of capsular dye in perform- ing iris repair is vital to its outcome as is the judicious use of capsular microforceps and scissors, Dr. Rosenthal stressed. "For those not willing to outlay the cost of the beautifully constructed instruments by MST, disposable, single-use vitreoretinal scissors and forceps are available from Alcon [Fort Worth, Texas] and Grieshaber [Alcon, Schaffhausen, Switzerland]. In this case, Dr. Safran did use VisionBlue (trypan blue, Dutch Ophthalmic, Exeter, N.H.), which ended up staining the vitreous. "It did not ruin the case, but made the surgery far more difficult," he said. Dr. Rosenthal's solution: "To avoid VisionBlue from migrating be- hind the capsule, obscuring the red reflex, retentive viscoelastic (either dispersive such as Healon EndoCoat [AMO] or Viscoat [Alcon], or pseudo- dispersive such as Healon 5) can be placed at the peripheral capsule to serve as a barrier." An added benefit of Healon 5 is that it may assist in the capsulorhexis by providing countertractional tamponade of the anterior capsular surface. Dr. Safran also used iris retrac- tors to help tear the capsule and hold the iris out of the way and in place while he performed other parts of the surgery. How it ended Many times an iris repair may end up disappointing for the patient. Because of this elegantly performed surgery, this was not one of those cases, Dr. Rosenthal said. "While I have had extensive ª5$7# W Woorld Ophthalmology Congress® of the International Council of Ophthalmology H ost: Japanese Ophthalmological Society Co-H ost: Asia-Pacific A cademy y of Op hthalmology t 999*7 *OUFSOBUJPOBM $POHSFTT PG 0QIUIBMNPMPHZ t t UI "TJ B 1BDJĕD "DBEFNZ PG 0QIUIBMNPMPHZ $POHSFTT UI "OOVBM.FFUJOH PG UIF +BQBOFTF 0QIUIBMNPMPHJDBM 4PDJFUZ experience with implantation of various types of iris prostheses, I agree with Dr. Safran's decision to perform the primary repair here, since the pupil will still dilate (and would be of a fixed diameter with an iris prosthesis) and since the use of the iris prosthesis would add ex- pense without significant clinical advantage," he said. "Nonetheless, I have performed many iris prosthetic implants in cases in which there is extensive iris damage, and particu- larly in cases of sphincter damage, fixed dilated pupils, multiple or extensive iridodialysis, or significant transillumination defects. In such cases, a primary repair is disappoint- ing more often than not." This patient ended up being 20/30 uncorrected and 20/20 with about 1 D of with-the-rule astigma- tism. Dr. Safran saw him recently, and he's currently 20/20. "The pupil has rounded out www.myreg gistration.net/woc2014_r g Join us Ap ril 2-6, 2014 www w..woc2014.o www www..facebook.com/woc2014 c2014.org twitter r..com/wo c2014 _ eg even more, providing better func- tion and cosmesis," Dr. Safran said. "He is very happy with the cosmetic outcome and has very good pupil function." EW Editors' note: Dr. Safran has no finan- cial interests related to this article. Dr. Rosenthal has financial interests with HumanOptics. Contact information Rosenthal: kr@eyesurgery.org Safran: safran12@comcast.net EW FEATURE February 2011 Challenging cataract cases October 2012

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